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Clinical evaluation of faecal incontinence and constipation

Clinical evaluation of faecal incontinence and constipation. By courtesy of Christine Norton PhD MA RN Nurse Consultant (Bowel Control) & Professor of Gastrointestinal Nursing St Mark’s Hospital & Kings College London, United Kingdom. Assessment – the evidence.

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Clinical evaluation of faecal incontinence and constipation

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  1. Clinical evaluation of faecal incontinence and constipation By courtesy of Christine Norton PhD MA RN Nurse Consultant (Bowel Control) & Professor of Gastrointestinal Nursing St Mark’s Hospital & Kings College London, United Kingdom

  2. Assessment – the evidence • No evidence-based assessment protocols • Informed opinion: history and physical examination most important • Clinicians often fail to examine • Physical environment and carers may be most important factor for immobile people

  3. What tests are needed? • Comprehensive history (Norton & Chelvanayagam, 2000) • Diary & symptom questionnaire • Physical examination • If bowel investigation needed: colonoscopy • Anorectal physiology tests? • Anal ultrasound? • If indicated: proctogram, bloods

  4. What goes wrong? • Anal sphincter (childbirth, injury, iatrogenic damage, degeneration) Internal anal sphincter - passive soiling External anal sphincter - urge incontinence • Gut motility (infection, inflammation, radiation, hypermotility, emotions) • Stool consistency (diet, motility, anxiety) • Local pathology (prolapse, piles, fistula) • Neurological damage (motor or sensory) • Lifestyle, toilets, drugs,immobility…

  5. History • Pre-morbid and current bowel symptoms • Timing of onset, is it worsening? • Faecal incontinence: • Urgency = loose stool or EAS problems • Passive loss = IAS problems or incomplete evacuation • Constipation: • Slow transit or evacuation difficulty (or both)?

  6. History • Co-morbidities and general health • Diet (amount, type and pattern) • Fluids (amount, type and pattern) • Toileting abilities, mobility, carers and toilet facilities • Medications • Lifestyle & psychosocial support • Depression and anxiety

  7. Stool form can give clues as to pathology • Loose stool more difficult to control • Hard stool suggests evacuation difficulty • Must ask about bleeding (bowel cancer second commonest cancer in UK) - refer to rectal bleeding clinic • Do not assume bleeding is piles

  8. One week diary gives a baseline Tick in shaded column when open bowels in toilet Tick in white column for incontinence or pad change More complex diaries may be needed for special groups

  9. Physical examination • Abdomen (masses, bladder) • Anal inspection (soiling, prolapse, scarring, haemorrhoids, gaping) • Digital anal (resting tone and squeeze) • Digital rectal (loading, masses) • Examine for prolapse on toilet • Vaginal (rectocele)

  10. Observing the perianal area • Rectal or vaginal prolapse • Haemorrhoids or skin tags • Wounds, lesions, discharge • Gaping anus • Skin condition • Bleeding • Stool, infestation and foreign bodies

  11. Rectal Prolapse

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